John Magill is a 75-year-old male with Parkinson’s disease, which he was diagnosed with five years ago. John was admitted to the hospital after falling at home. The physical examination revealed bruising on John’s hips and buttocks, as well as a tear on the right hip, but the X-ray did not reveal fractures in the lower extremities. The emergency department noted generalised tremor, decreased mobility, signs of confusion, agitation, and restlessness. The assessment of John’s vital signs showed that most measures are within expected ranges for an elderly person (temperature 37.2; respiratory rate 24; heart rate 76; oxygen saturation 99%). John’s blood pressure is slightly elevated at 145/80, but it does not warrant interventions aimed at reducing blood pressure at those levels. Immediately after drinking water given to him by the nursing staff, John started coughing, which indicates that he may have a problem with pulmonary aspiration. Parkinson’s disease is a possible neurogenic cause of pulmonary aspiration, and it increases the patient’s risk for aspiration pneumonia. Following the discussion of the possible causes of Parkinson’s disease, clinical manifestation, physical assessment procedures, and Mr. Magill’s current medical management program, a holistic nursing care plan and a discharge plan will be developed for Mr. Magill.
Possible Causes and Risk Factors of Parkinson’s
Although Parkinson’s disease is considered to be a sporadic disorder, heredity determines between 5% and 10% of Parkinson’s disease cases (Stell, 2015). According to Nalls et al. (2014), a total of 28 independent risk variants across 24 loci were identified for Parkinson’s disease, which was associated with changes in methylation or expression levels. The neurological pathogenesis of Parkinson’s is complex, but all patients show a loss of dopaminergic neurons in the substantia nigra pars compacta (Sulzer & Surmeier, 2013). The patients lose more than 60% of those neurons before they develop motor symptoms, which persist because the substantia nigra has an important role in the basal ganglia motor circuit.
In addition to biological factors, pesticides and solvents were found to be the most significant environmental determinants of Parkinson’s disease because they can increase risk for Parkinson’s by up to 80% (Pezzoli & Cereda, 2013). Exposure to such agents usually occurs in rural areas as a result of well-water drinking and exposure to organic pollutants in farming. Although most compounds associated with Parkinson’s disease are no longer used in industrialised nations, they are still sometimes used in developing countries.
Clinical Manifestation and Physical Assessment
Parkinson’s disease is usually characterised by motor symptoms, but non-motor symptoms are also an important consideration because they affect the patients’ quality of life and possibly inform nursing interventions. The three most common motor symptoms in Parkinson’s disease include resting tremor, bradykinesia, and rigidity, but patients can also experience gait freezing and postural instability (Nissen & Lau, 2015). Postural instability increases the risk of falls, and it is estimated that 60.5% of Parkinson’s disease patients report at least one fall, whereas 39% of them are estimated to fall repeatedly (Allen, Schwarzel, and Canning, 2013). Non-motor symptoms of Parkinson’s disease from the early stages include depression, fatigue, constipation, and sleep disturbances, whereas dementia becomes more common in the later stages of disease development (Nissen & Lau, 2015).
The diagnosis of Parkinson’s requires the presence of two of the three cardinal symptoms (i.e., resting tremor, bradykinesia, and rigidity), so the physical assessment needs to focus on those symptoms. Resting tremor assessment is performed by observing the patient in an outstretched position or by conducting a finger-to-nose test. Rigidity can be assessed by performing flexion and extension of the patient’s relaxed wrist, or the patients can be observed as they perform voluntary movements. Bradykinesia is first observed based on the patient’s blink rate and facial expression, followed by the assessment of stride length, walking speed, and arm swing while the patient is walking. Because John appears to be in an advanced stage of Parkinson’s, postural instability can be tested by assessing balance, and aspiration suggests the presence of dysphagia.
Medical Management
The current medical management of John’s condition includes three drugs: Citalopram (20 mgms daily), Kinson (1 tablet three times per day), and Madopar HBS 125 mgs controlled release capsules. Both Kinson and Madopar are antiparkinsonian agents, which are used to reduce dopamine deficiency and improve the muscular control to normalise the body movements of patients as much as possible (NPS MedicineWise, 2015a, 2015b). Levodopa is the active ingredient in both drugs, but Kinson also includes carbidopa, which serves as a synergistic agent that carries levodopa to the brain and distributes it to the relevant regions. Citalopram is selective serotonin reuptake inhibitor used to treat depression. Depression is one of the possible non-motor symptoms of Parkinson’s disease (Nissen & Lau, 2015), so it is possible to assume that the patient experiences depression as one of the disease’s non-motor symptoms.
Holistic Nursing Care Plans
Parkinsons’ disease is a risk factor for various complications associated with the progression of the condition, but based on the observations of John Magill, the most probable risks include falling, loss of motor control associated with ingestion, and risks associated with his medication management. Therefore, according to the (NANDA) taxonomy, the three most appropriate diagnoses are in order of importance: (a) risk for suffocation – 00036, (b) risk for falls – 00155, and (c) risk for chronic functional constipation – 00236.
The risk of suffocation is the most significant risk for John because it can lead to immediate death if the loss of motor functions is responsible for his pulmonary aspiration. Even if John does not suffocate because of pulmonary aspiration, he is at risk for aspiration pneumonia, which could prove to be fatal considering his old age. The goal of the nursing intervention for this diagnosis is to improve John’s motor control in the laryngeal and pharyngeal muscles. The nursing intervention can comprise of patient education and cognitive interventions. Through patient education, John and his wife will learn about appropriate physical positioning and oral intake (e.g., alternating liquid and solid foods) aimed at reducing risk of suffocation, whereas proper oral care education should decrease the risk of infections caused by aspiration. Cognitive interventions such as swallowing exercises and cues for reminding the patient to swallow (e.g., chin and throat stroking) should also be used to reduce the risk of suffocation.
Risk for falls is considered to be the second most important nursing diagnosis for John because approximately 39% of Parkinson’s disease patients fall more than once (Allen et al., 2013). Furthermore, John’s occasional alcohol consumption and medication management program may affect his balance in the future, thus increasing his probability of falls (Herdman & Kamitsuru, 2014). The goal of the nursing intervention is to reduce the risk for recurring falls in John’s case, and
that can be achieved with patient education and supervised exercise. Patient education needs to teach John and Fran how to create a home environment that minimizes the risk of falls and fall-related injuries (e.g., bathroom assistance utilities). Supervised exercise can be helpful for increasing motor control and balance in Parkinson’s disease patients, so it should help prevent falls in John’s case as well (Prodoehl et al., 2015).
The risk for chronic functional constipation is the least important diagnosis compared to the two other diagnoses, but it could affect John’s well-being and quality of life. This diagnosis was selected based on the fact that risk factors for functional constipation include depression and administration of antiparkinsonian agents (Herdman & Kamitsuru, 2014). For this diagnosis, the goal is to ensure that John’s gastrointestinal function of elimination is frequent. That can be achieved by monitoring John’s condition periodically via home visits to determine if he needs medication to alleviate constipation. Home visits conducted by a nurse are recommended because the patient suffers from mobility problems.
Discharge Plan
The patient education program should include both John and his wife Fran, and they should learn how to prevent falls and suffocation due to pulmonary aspiration. Fall prevention education and suffocation prevention education were discussed as a part of the holistic care plan and should be implemented before the patient is discharged. The hospital should provide John and his wife with relevant patient education brochures if available, as well as a list of useful resources they can use to learn more about Parkinson’s disease management, such as non-profit organisations or professional medical associations.
John and his wife can be referred to various health professionals after discharge. A referral to an occupational therapist is considered to be the most important because occupational therapy and supervised exercise were found to improve balance and quality of life in Parkinson’s disease patients (Liddle & Eagles, 2014; Prodoehl et al., 2015). A referral to the otolaryngologist can be useful for a more detailed assessment of John’s laryngeal dysfunction and dysphagia. Considering the fact that John is using an antidepressant as part of his medical management, a referral for counselling could also help improve John’s quality of life.
References
Allen, N. E., Schwarzel, A. K., & Canning, C. G. (2013). Recurrent falls in Parkinson’s disease: A systematic review. Parkinson’s Disease, 2013. http://dx.doi.org/10.1155/2013/906274
Herdman, T. H., & Kamitsuru, S. (2014). Nanda International, Inc. Nursing diagnoses: Definitions & classification 2015-2017. (10th ed.). West Sussex, UK: John Wiley & Sons.
Liddle, J., & Eagles, R. (2014). Moderate evidence exists for occupational therapy‐related interventions for people with Parkinson's disease in physical activity training, environmental cues and individualised programmes promoting personal control and quality of life. Australian Occupational Therapy Journal, 61(4), 287-288.
Nalls, M. A., Pankratz, N., Lill, C. M., Do, C. B., Hernandez, D. G., Saad, M., Singleton, A. B. (2014). Large-scale meta-analysis of genome-wide association data identifies six new risk loci for Parkinson’s disease. Nature Genetics, 46(9), 989–993. http://doi.org/10.1038/ng.3043
Nissen, L., & Lau, E. (2015). A bit of spice for parkinson's disease. Australian Pharmacist, 34(4), 36.
NPS MedicineWise. (2015a). Kinson tablets. Retrieved from http://www.nps.org.au/medicines/brain-and-nervous-system/movement-disorder-medicines/carbidopa-levodopa/kinson-tablets
NPS MedicineWise. (2015b). Madopar HBS 125 capsules. Retrieved from http://www.nps.org.au/medicines/brain-and-nervous-system/movement-disorder-medicines/levodopa-benserazide-hydrochloride/madopar-hbs-125-capsules
Pezzoli, G., & Cereda, E. (2013). Exposure to pesticides or solvents and risk of Parkinson disease. Neurology, 80(22), 2035-2041.
Prodoehl, J., Rafferty, M., David, F. J., Poon, C., Vaillancourt, D. E., Comella, C. L., Robichaud, J. A. (2015). Two year exercise program improves physical function in Parkinson’s disease: The PRET-PD study. Neurorehabilitation and Neural Repair, 29(2), 112–122. http://doi.org/10.1177/1545968314539732
Stell, R. (2015). Clinical edge: Recent advances in the genetics of Parkinson's disease. Medicus, 55(1), 40-43.
Sulzer, D., & Surmeier, D. J. (2013). Neuronal vulnerability, pathogenesis, and Parkinson's disease. Movement Disorders, 28(1), 41-50.
